The Roles and Responsibilities of Care …...The Roles and Responsibilities of Care Coordinators in...
Transcript of The Roles and Responsibilities of Care …...The Roles and Responsibilities of Care Coordinators in...
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The Roles and Responsibilities ofCare Coordinators in DHC
Frances Kam Yuet WongPresident, The Hong Kong Academy of NursingProfessor in Nursing & Associate Dean, Faculty of Health & Social SciencesThe Hong Kong Polytechnic University
17August 2019 (3:30 pm – 4:15 pm)Kwai Tsing District Health Centre
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Care Coordinator (CC)
Who is s/she?What does s/he do?
Who isn’t s/he?What does s/he not do?
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Key questions
Why DHC? Why the involvement of different stakeholders? Why CC?
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5
(Chow et al., 2013)
Hypertension
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Hong Kong
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An experience in Guangzhou
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Research site A community health
center (CHC) in Guangdong, China
100,000 residents ≈23,000 (23%)
hypertensive patients (Song & Meng, 2009)
≈10% hypertensive patients had healthcare records established
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Chronic Care Model
(Wagner, 1998)
Four-Cs Model(Wong, 2005)
NHM model Outcome
Self-management support
• A self-management booklet: knowledge and skills
• Behaviour contract• Health promotion
• BP • Self-care
behavior• Self-efficacy• QoL• Utilization of
healthcare service
• Patient satisfaction
Decision support
• Intervention protocols• A 36-hour training program• Regular meetings
Delivery system design
ComprehensivenessCollaboration Coordination Continuity
A nurse-led hypertension management team:• Home visit• Telephone follow-up• Referral
Clinical information system
• Health records• The Omaha System (Martin, 2005;
Wong et al., ?nd)
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Protocol-based intervention: Training protocol Protocol of home visit Protocol of telephone follow-up Protocol of assessment Protocol of intervention Protocol of referralProtocols were developed based on: Literature review Guidelines for hypertension management Expert consultant Pilot study (Zhu et al., 2014)
Development of the NHM model
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DBP readings in the control group and the study group at three time points
Results
SBP readings in the control group and the study group at three time points
T0: at recruitmentT1: immediately after interventionT2: 4 weeks after intervention
149.7
144.6
140.4
153.9
139.5 139.2
131.0133.0135.0137.0139.0141.0143.0145.0147.0149.0151.0153.0155.0
T0 T1 T2
Control group (n=67)
Study group (n=67)
83.5
80.8
78.4
82.6
75.3 75.2
69.0
71.0
73.0
75.0
77.0
79.0
81.0
83.0
85.0
T0 T1 T2
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0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
T0 T1 T20.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
T0 T1 T2
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
T0 T1 T20.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
T0 T1 T2
Adherence rate of anti-hypertensive drug Adherence rate of home BP monitoring
Adherence rate of salt restriction Adherence rate of regular physical activity
Adherence rate in the two groups at three time points
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An experience in Hong Kong
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Case 1
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Case 2
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Referral rate 14.3%
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http://www.improvingchroniccare.org/index.php?p=Care_Coordination_Model&s=353
A Case Study in Coordinated CareMs. H, Ms. G’s sister, is a 55-year-old grandmother with a 12-year history of Type 2 diabetes complicated by elevated blood pressure and recurrent episodes of major depression. … Her primary care doctor (PCP) postponed adjusting her hypoglycemic and anti-hypertensive drug doses until her depression was under better control, and referred her to the mental health center to review and update her depression treatment. ….
When Ms. H saw Dr. P (Psychiatrist), he had her clinical information in front of him. He adjusted her depression medication, but also found that her blood pressure was elevated. Ms. H also complained of headache and fatigue. Dr. P became alarmed about her blood pressure and headache, and arranged for her to be seen that afternoon by her PCP, who adjusted her anti-hypertensive medications. The receptionist/referral coordinator suggested that Ms. H have her BP checked by the EMTs at the neighborhood fire station every other day, which she did. Ms. H slowly began to feel less depressed and her BP slowly came down to target levels with one more medication adjustment.
What a CC is not?
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What is a CC in DHC?
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What is a CC in DHC?
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Thank you!
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